Endoscopy Findings Summary Letter (Referring Clinician)

Date: [Date of letter]

To: [Referring clinician name, credentials, clinic/service]

Re: [Patient full name, DOB]

Procedure: [Procedure type(s); procedure date; performing endoscopist]

Indication: [Indication(s) for the procedure]

Summary

[Brief summary acknowledging referral, procedure(s) performed, and headline result] (1-3 sentences. If pathology is pending, explicitly state this and note that recommendations may be updated.)

Findings

• [Clinically significant finding: description, location, size in mm for discrete lesions, severity/classification if it impacts management] (Order by clinical importance, not anatomy. Add additional findings as needed.)
• [Pertinent negative(s)] (Only include if clinically meaningful, e.g., no source identified when evaluating bleeding, key landmarks reached.)
• [Exam quality and completeness: extent reached, adequacy of visualization/prep, limitations] (Note impact on interpretation or surveillance intervals if applicable.)

Interventions & Specimens

• [Therapy performed: modality, target/location, immediate outcome] (Add additional interventions as needed. Specify if complete removal or hemostasis achieved.)
• [Specimen: source/location, test type] (Add additional specimens as needed.)
• Pathology status: [Pending / Final] (If pending, specify how results will be communicated. Do not assign histologic diagnoses until final; use "polyp(s) removed, histology pending" or similar.)

Impression

1. [Post-procedure diagnosis or synthesis] (Use qualifiers like "consistent with" or "suggestive of" if not confirmed. Add additional diagnoses as needed.)

Recommendations

• Treatment: [Medication changes with dose and duration if known] (Include only if applicable.)
• Antithrombotic management: [Resumption timing and agent(s)] (Include only if applicable.)
• Follow-up actions: [Required testing, imaging, labs, or referrals with timeframe] (Include only if applicable.)
• Surveillance interval: [Interval with brief rationale referencing risk category and exam quality] (Required. If pathology pending, provide provisional interval and state that final recommendation will follow. If deviating from guidelines, state reason.)
• Urgent findings: [Who was contacted and when] (Include only if urgent escalation occurred.)

Signature

[Endoscopist name, credentials, department]
Contact: [Phone and/or secure message route]

Addendum – Pathology Results

(Include only when issuing an addendum after pathology returns. This supersedes the provisional recommendation.)

• [Specimen diagnosis and key histology]
• [Updated risk category if changed]
• Updated surveillance interval: [Interval and rationale]
• [Additional treatment changes or referrals based on final pathology] (Include only if applicable.)